Health Care Roulette

Well, here we are at election season again.

No, not for the House and Senate but for your medical insurance plan. Whether you’re self-insured, a corporate employee, receive insurance thought the Affordable Care Act or are on Medicare Advantage or Medigap plans you must choose either to re-up with your existing plan or change your election to a competing plan. Miss the window and you are stuck or penalized.

To choose you will need to take into account changes in the plan you now have — which almost always means less coverage for more cost — changes in your family and in your health. In most of the developed world where single payer systems are in force, if you’re a citizen you get sick, you go to a doctor, your get treated and a tax you have paid provides the care you need. In our system, to choose wisely you will need the patience of Job and the skills of an MBA, a CPA and an MD just to sign up.

Those who think our system is superior must have a platinum plan provided by their employer, a team of lackeys to navigate the maze and so much loose change that they never have to worry about rising premiums, donut holes, and other bizarre surprises that suddenly bankrupt you or deny you coverage when you most need it. They are surely living in a dream world if they think the average person, and especially the elderly or gravely ill, can make sense of the choice they are presented with every fall. As you lie on a gurney with a morphine drip in your arm, you are asked, “So what will it be — Door Number One, Door Number Two or Door Number Three?

Do I want a high premium or low? Do I want a high deductible or low? That trade-off is the crux of the matter, a gamble that less premium cost monthly won’t come back to haunt me in the form of huge out of pocket costs if I suddenly get a serious illness, am sideswiped by a bus or my kid has a close encounter with a trampoline or middle linebacker.

Then there’s the impossible task of comparing a half-dozen or more plans to see which offers the best value or covers the most cataclysms. For starters, the charts and graphs are terse and confusing. And there’s no way to know what hidden explosives lurk in the fine print. If you are really serious, large book-length documents are offered so you can see if your doctor — or doctors — are all covered by the plan, if your prescriptions are covered.

Set aside about the same amount of time it takes for you to do your taxes for this step. But even if you seem to be covered today, who knows what tomorrow will bring. When you wake up one fine morning with a gallstone or ruptured disc or tropical disease, the specialist to which you are referred may be out-of-network, the drug you need may have been deemed too expensive by insurance gnomes in green eyeshades.

Your choice then is bankruptcy or death. All insurance is a crap shoot, of course. But the most you can lose with house or car insurance is a house or car, money in other words. But if you guess wrong with medical insurance you can lose your life when denied the help you need from the most competent people. But of course they don’t actually deny coverage and let you die. They take everything you own and your first born and all the money you have ever earned. Then you die.

Even the inherent gamble in choosing a plan might be tolerable if you could figure out what you are choosing, but the plans are incomprehensible. Often they do not appear to be written in English, rather like manuals for technology products or Ikea assembly instructions. I can choose, for example, between a MOOP of $3,700, $4,900 or $6,700. If I knew what a MOOP was, it would make the choosing easier. I am also admonished to consult the formulary carefully. Is Glaxadrobish covered or only the generic version, Xlripsilarf. Will that do? How do I know? Do I look like a pharmacist?

And when a bill arrives, the math seems to be about as opaque as the English used to describe it. Here’s a sample. For a given period, the amount providers have been billed by the plan is $2,023. The total cost the plan has approved is $631. Leapin’ Lizards, does that mean I owe the $1,400 difference? No, apparently not. The next column says the plan is actually only going to pay $454. This is just getting worse and worse. That seems to leave me with a bill for $1569. What’s the use of buying insurance at all? But wait, the final column says my share is actually only $168.

How did that happen? This literally doesn’t add up. The only plausible explanation is that doctors have provided care worth about 500 bucks, but knowing insurance companies will never pay the full amount of a bill they have quadrupled the amount they are asking for. Insurance companies, knowing the doctors are on to them, respond by saying, “No, the $2,000 is ridiculous. We will pay $600. But actually they only pay three-quarters of that and stick the insuree with the rest.

Middle Eastern rug merchants negotiate more honestly than this. If this isn’t a crazy way to run a railroad, let alone a life and death business, I’ll eat my formulary with a side order or MOOP. But first, I have to decide which plan to trust my fate to for the next 12 months. Time is running out. I must elect by Dec. 7, coincidently Pearl Harbor Day.

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